Basic Information
| Provider Information | |||||||||
| NPI: | 1134563042 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOUSTON ORTHOPEDIC SURGERY AND SPORTS MEDICINE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MIDDLE GEORGIA ORTHOPEDICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3051 WATSON BLVD STE 525 | ||||||||
| Address2: | |||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310938556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789534563 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1013 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PERRY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310693353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789534563 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2013 | ||||||||
| LastUpdateDate: | 03/08/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MALONE | ||||||||
| AuthorizedOfficialFirstName: | KEATHERN | ||||||||
| AuthorizedOfficialMiddleName: | SCOTT | ||||||||
| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 4789534563 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BC3200X | N | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment | 332B00000X | GA | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 300033915A | 05 | GA | MEDICAID |